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gi.acute-cholangitis.core.v1PRODUCTION
gi.acute-cholangitis.core.v1

Acute Cholangitis

gastroenterologyacuteadult
Hard-required inputs
0 / 9
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute biliary sepsis scope; differentiate from acute cholecystitis without ductal obstruction (ACG 2024)

Inputs
1
Actions
0
Advance rule
Set
Advance when

biliary obstruction + infection plausible

Patient inputs (12)

TG18 severity adjusts thresholds; geriatric mortality risk (ACG 2024)

Fever/chills core to Charcot triad (ACG 2024)

Hypotension defines TG18 Grade III; sepsis screen (ACG 2024)

Tachycardia for SIRS/sepsis (ACG 2024)

Leukocytosis + organ dysfunction stratifies TG18 grade (ACG 2024)

Cholestatic injury marker; TG18 diagnostic component (ACG 2024)

Cholestatic pattern confirmation (ACG 2024)

Renal organ dysfunction (TG18 III); contrast/abx dosing (ACG 2024)

First-line — CBD dilation, stones (ACG 2024)

Non-invasive ductal anatomy when US equivocal (ACG 2024)

Anatomy alters ERCP feasibility (ACG 2024)

Severity marker — sepsis / hypoperfusion (ACG 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningtg18_grade_iii_organ_failure
    TG18 grade III — organ dysfunction (cardiovascular, neurological, respiratory, renal, hepatic, hematological) (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningreynolds_pentad
    Charcot triad + AMS + hypotension/shock (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretg18_grade_ii
    TG18 grade II — moderate (WBC >12 or <4, fever ≥39, age ≥75, bilirubin ≥5, albumin <0.7× LL) (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefailed_ercp_drainage
    Failed endoscopic drainage OR ERCP contraindicated (altered anatomy, surgical Roux-en-Y) (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehepatic_abscess_complication
    CT/MRI shows pyogenic hepatic abscess complicating cholangitis (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Acute cholangitis — TG18 grade-driven antibiotics + biliary drainage (ACG 2024)
axis: cholangitis_TG18_pathwaystep 1 - Step 1 — Initial resuscitation + empiric antibiotics (any TG18 grade)
Selected step "Step 1 — Initial resuscitation + empiric antibiotics (any TG18 grade)" — Charcot triad / Reynolds pentad / cholestatic LFTs with ductal dilation
  • piperacillin_tazobactam
    first line
    BL_BLI
    4.5 g IV q6h (extended infusion 4h preferred in severe sepsis) • IV • q6h
    triggers: TG18_grade_II_III, healthcare_associated, severe_sepsis
    Tokyo Guidelines 2018 — broad-spectrum gram-neg + anaerobic; preferred when ESBL/Pseudomonas risk
    rxcui 74169
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    2 g IV daily • IV • daily
    triggers: TG18_grade_I_II_community_acquired
    TG18 — community-acquired, mild-moderate; pair with metronidazole if anaerobic concern (gallstone pancreatitis, prior biliary surgery) (ACG 2024)
    rxcui 2193
  • metronidazole
    add on
    nitroimidazole
    500 mg IV q8h • IV • q8h
    triggers: anaerobic_concern, prior_biliary_surgery
    Add to ceftriaxone for anaerobic coverage in selected cases
    rxcui 6922
  • meropenem
    second line
    carbapenem
    1 g IV q8h • IV • q8h
    triggers: ESBL_risk, recent_carbapenem_susceptibility, severe_sepsis_TG18_III
    Reserve for severe sepsis with ESBL risk; healthcare-associated
    rxcui 29561
  • normal_saline_or_LR
    first line
    crystalloid
    30 mL/kg IV bolus over 3h (Surviving Sepsis 2021) • IV • bolus then maintenance
    triggers: sepsis_septic_shock
    Sepsis bundle resuscitation
    rxcui 9863

ed playbook — drug actions (5)

  1. 1. crystalloid resuscitation
    30 mL/kg IV LR over 3h • IV • bolus
    trigger: Sepsis/septic shock (ACG 2024)
    Surviving Sepsis 2021
  2. 2. pip-tazo
    4.5 g IV q6h (after cultures) • IV • q6h
    trigger: TG18 grade II/III OR healthcare-associated (ACG 2024)
    TG18 broad-spectrum (ACG 2024)
  3. 3. ceftriaxone + metronidazole (alternative)
    Ceftriaxone 2 g IV daily + metronidazole 500 mg IV q8h • IV • daily + q8h
    trigger: TG18 grade I community-acquired (ACG 2024)
    Community-acquired narrow-spectrum option (ACG 2024)
  4. 4. meropenem
    1 g IV q8h • IV • q8h
    trigger: ESBL risk OR severe sepsis (TG18 grade III) (ACG 2024)
    TG18 — severe sepsis or healthcare-associated (ACG 2024)
  5. 5. norepinephrine
    0.05-0.5 mcg/kg/min titrated • IV • continuous
    trigger: MAP <65 despite 30 mL/kg fluids (ACG 2024)
    Septic shock (ACG 2024)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Charcot triad — fever + RUQ pain + jaundice (ACG 2024); Reynolds pentad — Charcot + AMS + shock (ACG 2024); Cholestatic LFTs (ALP/GGT/bilirubin elevated) (ACG 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Cholangitis** (gi.acute-cholangitis.core.v1).
Phenotype framing: Confirm cholangitis vs acute cholecystitis, hepatic abscess, viral hepatitis, pancreatitis (ACG 2024)
Scope: Confirm acute biliary sepsis scope; differentiate from acute cholecystitis without ductal obstruction (ACG 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute cholangitis — TG18 grade-driven antibiotics + biliary drainage (ACG 2024)** — step "Step 1 — Initial resuscitation + empiric antibiotics (any TG18 grade)".
1. piperacillin_tazobactam 4.5 g IV q6h (extended infusion 4h preferred in severe sepsis) IV q6h (BL_BLI, first line) — Tokyo Guidelines 2018 — broad-spectrum gram-neg + anaerobic; preferred when ESBL/Pseudomonas risk
2. ceftriaxone 2 g IV daily IV daily (cephalosporin_3rd_gen, first line) — TG18 — community-acquired, mild-moderate; pair with metronidazole if anaerobic concern (gallstone pancreatitis, prior biliary surgery) (ACG 2024)
3. metronidazole 500 mg IV q8h IV q8h (nitroimidazole, add on) — Add to ceftriaxone for anaerobic coverage in selected cases
4. meropenem 1 g IV q8h IV q8h (carbapenem, second line) — Reserve for severe sepsis with ESBL risk; healthcare-associated
5. normal_saline_or_LR 30 mL/kg IV bolus over 3h (Surviving Sepsis 2021) IV bolus then maintenance (crystalloid, first line) — Sepsis bundle resuscitation

Setting playbook (ed) — Recognize cholangitis, draw cultures, start empiric antibiotics within 1h, fluid resuscitate, expedite imaging (RUQ US ± MRCP), arrange ERCP within 24h (or sooner if grade III) (ACG 2024)
6. crystalloid resuscitation 30 mL/kg IV LR over 3h IV bolus — Sepsis/septic shock (ACG 2024) (Surviving Sepsis 2021)
7. pip-tazo 4.5 g IV q6h (after cultures) IV q6h — TG18 grade II/III OR healthcare-associated (ACG 2024) (TG18 broad-spectrum (ACG 2024))
8. ceftriaxone + metronidazole (alternative) Ceftriaxone 2 g IV daily + metronidazole 500 mg IV q8h IV daily + q8h — TG18 grade I community-acquired (ACG 2024) (Community-acquired narrow-spectrum option (ACG 2024))
9. meropenem 1 g IV q8h IV q8h — ESBL risk OR severe sepsis (TG18 grade III) (ACG 2024) (TG18 — severe sepsis or healthcare-associated (ACG 2024))
10. norepinephrine 0.05-0.5 mcg/kg/min titrated IV continuous — MAP <65 despite 30 mL/kg fluids (ACG 2024) (Septic shock (ACG 2024))

Non-pharmacologic actions:
- NPO (ACG 2024)
- IV access × 2 (ACG 2024)
- Foley if UOP monitoring needed (ACG 2024)
- Source control — emergent ERCP for grade III; within 24-48h for grade II; within 24-48h for grade I if not improving (ACG 2024)
- IR consult for PTBD if ERCP fails or contraindicated (ACG 2024)
- Hepatology / GI consult on admission (ACG 2024)

AVOID / contraindication checks:
- No_oral_intake_until_drainage_complete_in_severe (ACG 2024)
- De_escalate_antibiotics_per_culture_24_72h (ACG 2024)
- Carbapenem_reserved_for_ESBL_or_severe (ACG 2024)
- NSAID_avoid_in_septic_AKI (ACG 2024)

Monitoring

Regimen monitoring:
- serial LFTs daily (ACG 2024)
- lactate clearance q6h (ACG 2024)
- blood culture followup (ACG 2024)
- temperature q4h (ACG 2024)
- response to drainage within 24h (ACG 2024)
- duration 4 to 7 days of antibiotics if drained and responding (ACG 2024)

Setting (ed) monitoring:
- Continuous vitals + telemetry (ACG 2024)
- Lactate q2-4h (ACG 2024)
- Hourly UOP in shock (ACG 2024)
- SpO2 (ACG 2024)
- Daily LFTs (ACG 2024)

Follow-up plan: Interval cholecystectomy after stone-related cholangitis; LFT normalization; recurrence counseling (ACG 2024)
- Close-out criterion: follow-up scheduled

Monitoring phase: Serial vitals, daily LFT trend, lactate clearance, response to drainage (ACG 2024)

Disposition

Current setting: ed — Recognize cholangitis, draw cultures, start empiric antibiotics within 1h, fluid resuscitate, expedite imaging (RUQ US ± MRCP), arrange ERCP within 24h (or sooner if grade III) (ACG 2024)

Disposition criteria:
- Admit ward: TG18 grade I-II responding to abx (ACG 2024)
- Admit ICU: TG18 grade III, septic shock, failed ED resuscitation (ACG 2024)
- OR/IR: emergent for failed endoscopic drainage (ACG 2024)

Escalation triggers (move to higher acuity):
- TG18 grade III (organ dysfunction) → ICU + emergent ERCP within hours (ACG 2024)
- Refractory shock → ICU + vasopressors (ACG 2024)
- Hepatic abscess → IR drainage (ACG 2024)
- Failed ERCP → PTBD or surgical decompression (ACG 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] TG18 grade III — organ dysfunction (cardiovascular, neurological, respiratory, renal, hepatic, hematological) (ACG 2024)
- [LIFE_THREATENING] Charcot triad + AMS + hypotension/shock (ACG 2024)
- [SEVERE] TG18 grade II — moderate (WBC >12 or <4, fever ≥39, age ≥75, bilirubin ≥5, albumin <0.7× LL) (ACG 2024)

Citations

- Tokyo Guidelines 2018 (TG18) — Acute Cholangitis: diagnostic criteria, severity grading, management flowchart and antimicrobial therapy [PMID:29032610](https://pubmed.ncbi.nlm.nih.gov/29032610/)
- Cited evidence (PMID 28941329) [PMID:28941329](https://pubmed.ncbi.nlm.nih.gov/28941329/)
- Cited evidence (PMID 29090866) [PMID:29090866](https://pubmed.ncbi.nlm.nih.gov/29090866/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Tokyo Guidelines 2018 (TG18) — Acute Cholangitis: diagnostic criteria, severity grading, management flowchart and antimicrobial therapy — PMID:29032610
  • Cited evidence (PMID 28941329) — PMID:28941329
  • Cited evidence (PMID 29090866) — PMID:29090866